Central Sewer Billing Application

TANEY COUNTY REGIONAL SEWER DISTRICT
CENTRAL SEWER BILLING APPLICATION
PO BOX 563, FORSYTH, MO 65653 - (417) 546-7221

SECTION I
PROPERTY OWNER'S NAME: SSN:
ADDRESS:
Street or PO Box City State Zip
911 ADDRESS (IF DIFFERENT):
Street City State Zip
PHONE NUMBER ( WITH AREA CODE):
SSN: ___________________ LIC#

SECTION II
RENTER'S NAME (IF DIFFERENT): SSN: :
ADDRESS:
Street or PO Box City State Zip
911 ADDRESS (IF DIFFERENT):
Street City State Zip
PHONE NUMBER ( WITH AREA CODE): ( )
Monthly Sewer Bill sent to Renter: Yes _____ No _____
SSN: _____________________LIC# ________________________________________

(Property Owner is utimately responsible for payment of sewer bill)

SECTION III
A COPY OF PROOF OF OWNERSHIP IS REQUIRED WITH ALL APPLICATIONS. THIS
CAN BE A COPY OF YOUR WARRANTY DEED OR A COPY OF YOUR PAID PROPERTY
TAX FOR THE PAST YEAR.

SECTION IV
A SECURITY DEPOSIT WILL BE REQUIRED AT THE TIME OF THE SUBMISSION OF
YOUR APPLICATION FOR CONNECTION TO THE COUNTY'S SEWER SYSTEM.

RESIDENTIAL: $50.00 COMMERCIAL: $100.00

SECURITY DEPOSIT WILL BE PAID BY: PROPERTY OWNER RENTER

SECTION V
PLEASE READ BEFORE SIGNING:
In signing this application, I understand that if the information provided herein is not true, my permit
will be revoked. I further understand and agree to abide by the requirements of the Taney County
Regional Sewer District. The Taney County Regional Sewer District assumes no liability for the installa-
tion or performance of any sewer system other than its own. I agree to all inspections on my property
deemed necessary to secure compliance with all County codes relevent to this application.

PROPERTY OWNER'S/RENTER'S SIGNATURE:
Application not valid without signature of owner/renter Date

SECTION VI
FOR OFFICE USE ONLY - DO NOT FILL IN
CONNECTION FEE: DATE PAID RECEIVED BY
DEPOSIT AMOUNT: DATE PAID POSTED REC'D BY
ACCOUNT # RECEIPT #